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Dictated Physician Encounter Note
DATE: 12/29/2010 13:45
REASON FOR CONSULTATION: Acute myocardial infarction.
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old without significant past medical history on no
medication. He is a heavy smoker who comes to the Emergency Room with 2 days of chest pain. The
patient started to have pain sometime on Saturday during the day. It was in her chest radiating up to her
neck as it also hurt to breathe. This persisted for the next 2 days. She called her friend Monday morning,
brought her to the Emergency Room. She is complaining of ongoing chest pain which she feels is similar
to her presenting pain; however, it hurts to move or to take deep breaths as it goes up to her neck and
jaw. It is a little better sitting forward. She has not had any of this discomfort prior to the onset on
Saturday.
Her risk factors are she smokes at least 1 pack a day. She was young and question whether she has
hypertension, but she is not treated. She has no diabetes from looking in her record on SRS. She did have
an elevated LDL of 150 back in 2007 and is not on treatment and drinks at least moderate alcohol.
Her son and friend were with her when I examined the patient. She was clearly in some
distress and complaining of his discomfort. Difficult to get a good complete history since
the patient is in distress.
Her CK-MB and troponin I were 3173, 98.8 and 58.7, respectively,
BUN 23, creatinine 1.3, AST 607, ALT 53, alkaline phosphatase 130. Her white count 18.5, hemoglobin
15.4, hematocrit 45.9. Her MCV 108.6, increased absolute neutrophil count of 16%, normal INR and
electrocardiogram showed inferior myocardial infarction with ST depression of up to 2 mm, particularly
in V3, 4 and 5. Chest x-ray showed what appeared to be cardiomegaly without congestive heart failure.
On exam, her blood pressure was in 180/70, her pulse 104. Skin was warm and dry. She appeared in
some distress. Neck was supple. Carotid: No bruits. No jugular venous distention. Lungs were clear. She
had normal heart sounds with what appeared to be a gallop rhythm and a 2/6 systolic murmur at the
apex. Point of maximal impulse was somewhat displaced laterally. Abdomen was soft. Extremities, she
had good peripheral pulses, no cyanosis, clubbing, or edema.
A stat echocardiogram done showed a very extensive inferior, posterior and lateral areas of akinesis; her
anterior wall contracting normally. She had moderate mitral regurgitation, mild-to-moderate tricuspid
regurgitation with an elevated pulmonary artery pressure estimate probably around 50 and there was
no significant pericardial effusion.
ASSESSMENT AND PLAN: This is a 51-year-old who has had an extensive inferior posterior
lateral myocardial infarction and moderate mitral regurgitation as a consequence. She is not in heart
failure and apparently her myocardial infarction began on Saturday and is ongoing. Whether her pain is
now all infarct pericardotomy syndrome or ongoing ischemia is unclear. She says pain is the same
although there is a pleuritic component. She does have ongoing ischemic ST depression of up to 2 mm,
which could represent posterior infarct. At this point, I would proceed to cardiac catheterization and
recommendations will be pending the results.
Discharge Plan:
1) beta blocker c lopressor 50mg PO BID
2) Start Cardiac diet
3) Follow up 3 months
4) Lipid profile
Dictated by: Dr Cardiology, MD
Recommendation: Consider
changing diagnosis to “Healthcare
Associated Pneumonia (HAI)”
Reasoning: Previous history of
hospitalization in the past 3 weeks
Source: HIE
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